National Diabetes Inpatient Audit – Harms, 2019

Data Quality Statement

Published 13 November 2020

## Contents

| Section | Page | |------------------------------------------------------------------------|------| | Introduction | 3 | | Relevance | 3 | | Linkage to the core National Diabetes Audit (NDA) | 4 | | Linkage to Hospital Episode Statistics (HES) | 4 | | NDA-HES linkage | 4 | | **Timeliness and Punctuality** | 4 | | **Accuracy, Reliability and Limitations** | 5 | | **Coherence and Comparability** | 5 | | Comparability over time | 5 | | Comparability with other sources | 6 | | **Confidentiality, Transparency and Security** | 7 | | **Accessibility and Clarity** | 7 | | **Assessment of User Needs and Burden on respondents** | 7 | | Providing feedback | 8 | Introduction

The National Diabetes Inpatient Audit (NaDIA) is part of the National Diabetes Audit (NDA) portfolio within the National Clinical Audit and Patient Outcomes Programme (NCAPOP), commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England.

NaDIA-Harms is a continuous collection of serious inpatient harms that can affect people with diabetes. NaDIA-Harms began data collection on 1 May 2018. All acute hospitals in England with inpatients with diabetes are eligible to participate. The Welsh government decided not to participate in the NaDIA-Harms collection. Consequently, health services in Wales are not eligible to participate.

NaDIA-Harms is the companion collection to the annual NaDIA snapshot audit of diabetes inpatient care in England and Wales, which has been undertaken since 2010. A link to the 2019 NaDIA snapshot report published on 13 November 2020 can be found here: http://digital.nhs.uk/pubs/nadia2019.

Relevance

NaDIA-Harms collects data on occurrences of the following serious inpatient harms that can affect people with diabetes:

- hypoglycaemia requiring rescue treatment
- diabetic ketoacidosis (DKA)
- hyperglycaemic hyperosmolar state (HHS)
- new diabetic foot ulceration (DFU)

The objective of NaDIA-Harms is to help reduce the rates of these serious inpatient harms by providing case-mix adjusted benchmarked feedback and identifying patients at risk to hospital trusts and inform quality improvement work. Monitoring and improving participation are important first steps towards meeting this objective.

The 2019 NaDIA-Harms report includes analysis on participation, a count of the number of participants and harms, and the estimated case ascertainment of each inpatient harm based on the NaDIA 2019 snapshot collection. The report also includes patient profiles of each inpatient harm, which comprise of demographics, diabetes characteristics, treatment targets, care processes, admission characteristics and comorbidities. These were produced through linkage to core National Diabetes Audit (NDA) and Hospital Episode Statistics (HES) data.

All analyses within the report are based on the first 18 months of the collection (1 May 2018 to 31 October 2019), with NaDIA-Harms data extracted on 4 December 2019.

This report will be of interest to the public, especially to people with diabetes. Health planners and policy makers, as well as acute NHS Trusts, Clinical Commissioning Groups (CCGs), Local Health Boards (LHBs), Sustainability and Transformation Partnerships (STPs), Clinical Networks (CNs; formerly Strategic Clinical Networks or SCNs) and other providers and commissioners of specialist diabetes services will also make use of the information in this report. Linkage to the core National Diabetes Audit (NDA)

Patients in NaDIA-Harms were linked to data items recorded in the core NDA, including NDA data up to 31 March 2019. The core National Diabetes Audit (NDA) collects data on patient demographics, care processes and treatment targets amongst those registered with participating GP practices and secondary care organisations in England and Wales. The majority of core NDA data is from primary care: 98.3 per cent of patients in the 2017-2018 NDA (covering 1 January 2017 to 31 March 2018) were from primary care records. 98.0 per cent of general practices in England and Wales participated in the latest published full core NDA reporting period (2018-2019 NDA, covering 1 January 2018 to 31 March 2019).

92.8 per cent of the patients in NaDIA-Harms were found in the core NDA. Age at start of NDA year, sex, ethnicity, diabetes type and diabetes duration at start of NDA year were taken from the core NDA demographics table. Smoking status, body mass index (BMI), renal function and deprivation quintile took the value in NDA closest to the inpatient harm date (in the corresponding NDA year or one of the preceding three years). NDA treatment targets and care processes were taken from the NDA year preceding the inpatient harm year (defined as April to March).

Linkage to Hospital Episode Statistics (HES)

HES is a database containing details of all admissions, outpatient appointments and Accident and Emergency attendances at NHS hospitals in England. NaDIA-Harms patients were linked to hospital admissions data in HES, with admissions data available up to 30 November 2019.

Hospital admissions covering the date of the inpatient harm were found for 87.9 per cent of episodes in NaDIA-Harms.

NDA-HES linkage

A comparison population of inpatients with diabetes was created by linking people in the NDA to hospital admissions in HES 2018-19.

Resultant comparisons between the NaDIA-Harms-HES cohort and the NDA-HES 2018-19 cohort used bed days rather than patients or admissions as the unit of currency, which adjusted for the length of the hospital stay. Bed days on which a patient’s harm was reported to NaDIA-Harms were removed from the NDA-HES 2018-19 baseline cohort.

Timeliness and Punctuality

The NaDIA-Harms collection opened on 1 May 2018. The 2019 NaDIA-Harms report was built using data extracted from the NaDIA-Harms database on 4 December 2019. Counts of harms and participating organisations are derived from harms that occurred between 1 May 2018 and 31 October 2019 (the cohort), covering the first 18 months of data collection. The planned publication date was 14 May 2020. However, publication was delayed by six months due to the COVID-19 pandemic and the report was published on 13 November 2020. The time lag to the publication of the main report was therefore thirteen months after the end of the cohort (31 October 2019) and eleven months after the initial outputs were generated (4 December 2019). Accuracy, Reliability and Limitations

Participation in NaDIA-Harms is voluntary, but encouraged, for all acute NHS trusts in England admitting patients with diabetes. 108 NHS trusts registered for NaDIA-Harms between 1 May 2018 and 4 December 2019. 100 of these 108 NHS trusts participated in NaDIA-Harms between 1 May 2018 and 31 October 2019 (the audit period). An NHS trust is classed as having participated if they either:

a) submitted one or more harm; or b) confirmed a null return for one or more month during the audit period. 51 NHS trusts submitted on a regular basis, defined as having met criteria a) or b) above in each quarterly period between May 2018 and October 2019 (starting May to July 2018).

For comparison, 131 NHS trusts in England are known to be eligible for the NaDIA snapshot, with eligibility inferred from participation in the NaDIA snapshot collections between 2015 and 2019. This suggests NaDIA-Harms participation is around 76 per cent of applicable NHS trusts (100 of 131).

2,905 inpatient harms were recorded in NaDIA-Harms during the audit period. Based on comparable data collected in the NaDIA 2019 snapshot, estimated case ascertainment in NaDIA-Harms ranged from only 6-8 per cent (hypoglycaemic rescue, HHS, DFU) to 20 per cent (DKA).

The audit does not collect data from outside England.

Coherence and Comparability

Comparability over time

Table 1 shows that, following an initial rise from 69 to 83, the number of participating NHS trusts has not changed substantially since the second quarterly period of NaDIA-Harms collection, with the number of participants fluctuating between 78 and 88. Because NHS trusts can verify monthly nil submissions, fluctuations in the underlying number of harms should not affect the number of participants.

Table 1: Number of participating1 NHS trusts, by quarterly period where inpatient harm occurred, England, May 2018 - October 2019

| Quarterly period | Number of trusts participating | |------------------------|-------------------------------| | May - Jul 2018 | 69 | | Aug - Oct 2018 | 83 | | Nov 2018 - Jan 2019 | 87 | | Feb - Apr 2019 | 88 | | May - Jul 2019 | 79 | | Aug - Oct 2019 | 78 | | **Total** | **100** |

*Source: NHS Digital*

*Notes: 1. One or more inpatient harm submission or any verified monthly nil submission in the quarterly period.* The number of inpatient harms submitted on a quarterly basis increased from 325 in quarter 1 (May-June 2018), reaching a peak of 610 in quarter 3 (November 2018-January 2019), before reducing to 425 in the final quarterly period (August-October 2019). It is not known to what extent this trend reflects changes in NaDIA-Harms participation or real changes in the underlying occurrence of harms (e.g. seasonal changes).

Table 2: Number of episodes, by inpatient harm, by quarterly period that inpatient harm occurred, England, May 2018 - October 2019 (rounded¹)

| Inpatient harm | May - Jul 2018 | Aug - Oct 2018 | Nov 2018 - Jan 2019 | Feb 2019 | May - Jul 2019 | Aug - Oct 2019 | Total | |-------------------------|----------------|----------------|---------------------|----------|----------------|----------------|-------| | Hypoglycaemic rescue | 210 | 340 | 445 | 405 | 350 | 300 | 2,055 | | DKA | 50 | 85 | 80 | 80 | 70 | 75 | 440 | | HHS | 5 | 15 | 25 | 15 | 15 | 10 | 80 | | Diabetic foot ulcer | 55 | 50 | 60 | 70 | 50 | 40 | 330 | | Total | 325 | 490 | 610 | 570 | 485 | 425 | 2,905 |

Source: NHS Digital

Notes: 1. Counts have been rounded. Counts between 1 and 7 are represented as a 5. All counts greater than 7 have been rounded to the nearest five. Consequently, the total will not usually match the sum of the four constituent inpatient harms.

Comparability with other sources

Since 2010, the NaDIA snapshot audit has collected information on the incidence of patient harms during a specified week in September, including the four patient harms collected in the continuous NaDIA-Harms audit. The last NaDIA snapshot data on patient harms was collected in September 2019 and published in the 2019 NaDIA report published on 13 November 2020.

Patient harms in the NaDIA snapshot are reported as a proportion of inpatients experiencing the harm during their hospital stay (diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS), new diabetic foot ulceration (DFU)) or in the previous seven days of their hospital stay (hypoglycaemia requiring rescue treatment).

Direct comparison between the collections is possible by adjusting for the different methodology and collection periods of the two collections. This analysis has been done for the 2019 NaDIA-Harms report in order to produce estimated case ascertainment for each inpatient harm. Based on comparable data collected in the NaDIA 2019 snapshot, estimated case ascertainment in NaDIA-Harms ranges from 6-8 per cent (hypoglycaemic rescue, HHS, DFU) to 20 per cent (DKA).

No other data source provides equivalent information about the incidence of inpatient harms in England. Confidentiality, Transparency and Security

Audit information is held securely and with restricted access.

It is expected that, through the audit collection, all organisations will continue to follow existing NHS codes of practice about patient confidentiality, information security management, record management and other legal obligations.

A risk assessment has been carried out on the audit publication to identify risks to patient confidentiality. Rounding has been used for numbers derived from harms records to reduce the risk of patient identification; numbers 1-7 are shown as 5, while all other numbers are rounded to the nearest 5. Percentages will be calculated using rounded numerators and denominators and shown to one decimal place. The calculated value will not be shown in cases where the denominator is less than 20. Statistical calculations (e.g. significance tests) are performed on unrounded numbers.

In line with the government transparency agenda, NHS Digital provides local participation data taken from the audit, in CSV format, as part of the audit publication available through the NHS Digital website, and also through the UK open data portal, https://data.gov.uk.

Accessibility and Clarity

The main report is presented in both PowerPoint and PDF formats on the NHS Digital website, with supporting data accompanying the report as Excel spreadsheets, with backing data also provided in CSV format. A CSV of data from England organisations at national-level is available on the NHS Digital website and through data.gov.uk. All the above reports are available on the NHS Digital website at: http://digital.nhs.uk/pubs/nadia-harms2019.

Further information about the NaDIA-Harms audit may be found at: https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/national-diabetes-in-patient-audit-nadia-harms.

Information about the NaDIA snapshot can be found at: https://digital.nhs.uk/nadia.

The 2019 NaDIA snapshot report can be found at: http://digital.nhs.uk/pubs/nadia2019.

Assessment of User Needs and Burden on respondents

The NaDIA advisory group and NaDIA-Harms advisory group (consisting of patient representatives, healthcare professionals, administrators, researchers and analysts, including representation from Diabetes UK and NHS Digital) provide advice on the content of the reports as well as the direction and development of the audit.

The wider National Diabetes Audit (NDA) team has an active role in the National Cardiovascular Intelligence Network (NCVIN) workshops to gain a better understanding of how Clinical Commissioning Groups (CCGs) and localities use the data and how we can improve the NDA programme’s publications and supporting information. These workshops are conducted quarterly and are co-ordinated by Public Health England (PHE) and bring together epidemiologists, analysts, clinicians and patient representatives. NaDIA-Harms is designed to be a low-burden collection, with only four data items required from submitters:

- NHS number: for data validation and linkage
- harm type: hypoglycaemia requiring rescue treatment, diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS), new diabetic foot ulceration (DFU)
- date the harm occurred
- hospital site at which the harm occurred

The audit team acknowledges that participation in the audit involves costs in both time and organisation for the providers that take part, and thanks them for their efforts. The audit continues to look at ways in which to reduce respondent burden and increase ease of participation and welcomes comments and suggestions.

**Providing feedback**

NHS Digital is keen to gain a better understanding of the users of this publication and their needs, as well as welcome suggestions on how to decrease respondent burden.

Your feedback is welcome and may be sent to enquiries@nhsdigital.nhs.uk. Please include ‘National Diabetes Inpatient Audit’ in the subject line.

Alternatively, you can call our contact centre on 0300 303 5678

Or write to:

NHS Digital, 1 Trevelyan Square, Boar Lane, Leeds, LS1 6AE.